Provider Demographics
NPI:1871228973
Name:BLISSFUL MINDS LLC
Entity type:Organization
Organization Name:BLISSFUL MINDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:OMOTOLU
Authorized Official - Middle Name:OLAITAN
Authorized Official - Last Name:AJE-OMOKORE
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:316-990-4126
Mailing Address - Street 1:10401 MONTGOMERY PKWY NE STE 1A
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-3876
Mailing Address - Country:US
Mailing Address - Phone:505-595-2680
Mailing Address - Fax:
Practice Address - Street 1:10401 MONTGOMERY PKWY NE STE 1A
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-3876
Practice Address - Country:US
Practice Address - Phone:505-595-2680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-21
Last Update Date:2022-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1548699739Medicaid
TX1841624855Medicaid